Leukemia

Leukemia

Diagnosis

Treatment

Survivorship

Leukemia

Leukemia is a type of blood cancer that begins in the bone marrow. Bone marrow is the soft tissue in the center of the bones, where blood cells grow. The term "leukemia" literally means "white blood." White blood cells (leukocytes) are used by the body to fight off infections and other foreign substances. They are made in the bone marrow.

Leukemia leads to an uncontrolled increase in the number of white blood cells.

The cancer cells spread to the bloodstream and lymph nodes. They can also travel to the brain and spinal cord (the central nervous system) and other parts of the body.

Leukemias are divided into two major types:

Acute (which progresses quickly)

Chronic (which progresses more slowly)

Acute lymphocytic leukemia (ALL)

Acute lymphocytic leukemia (ALL) is a fast-growing cancer of a type of white blood cells called lymphocytes. These cells are found in the bone marrow and other parts of the body.

Causes, incidence, and risk factors

Acute lymphocytic leukemia (ALL) occurs when the the body produces a large number of immature white blood cells, called lymphocytes. The cancer cells quickly grow and replace normal cells in the bone marrow. Bone marrow is the soft tissue in the center of bones that helps form blood cells. ALL prevents healthy blood cells from being made. Life-threatening symptoms can occur.

This type of leukemia usually affects children ages 3 - 7. It is the most common childhood acute leukemia. However, the cancer may also occur in adults.

Most of the time, there is no obvious cause. However, the following may play a role in the development of leukemia in general:

Causes, incidence, and risk factors

Acute myeloid leukemia (AML) is one of the most common types of leukemia among adults. This type of cancer is rare under age 40. It generally occurs around age 60. (This article focuses on AML in adults.)

AML is more common in men than women.

Persons with this type of cancer have abnormal cells inside their bone marrow. The cells grow very fast, and replace healthy blood cells. The bone marrow, which helps the body fight infections, eventually stops working correctly. Persons with AML become more prone to infections and have an increased risk for bleeding as the numbers of healthy blood cells decrease.

Most of the time, a doctor cannot tell you what caused AML. However, the following things are thought to lead to some types of leukemia, including AML:

Certain chemicals (for example, benzene)

Certain chemotherapy drugs, including etoposide and drugs known as alkylating agents

Radiation

Problems with your genes may also play a role in the development of AML.

You have an increased risk for AML if you have or had any of the following:

A weakened immune system (immunosuppression) due to an organ transplant

Blood disorders, including:

Polycythemia vera

Essential thrombocythemia

Myelodysplasia (refractory anemia)

Exposure to radiation and chemicals

Symptoms

Bleeding from the nose

Bleeding gums

Bruising

Bone pain or tenderness

Fatigue

Fever

Heavy menstrual periods

Pallor

Shortness of breath (gets worse with exercise)

Skin rash or lesion

Swollen gums (rare)

Weight loss

Chronic lymphocytic leukemia (CLL)

Chronic lymphocytic leukemia is cancer of a type of white blood cells called lymphocytes.

Causes, incidence, and risk factors

Chronic lymphocytic leukemia (CLL) causes a slow increase in white blood cells called B lymphocytes, or B cells. The cancerous cells spread from the blood marrow to the blood, and can also affect the lymph nodes or other organs such as the liver and spleen. CLL eventually causes the bone marrow to fail.

IThe cause of CLL is unknown. There is no link to radiation, cancer-causing chemicals, or viruses.

This cancer mostly affects adults, around age 70. It is rarely seen under age 40. The disease is more common in Jewish people of Russian or East European descent.

Symptoms

Symptoms usually develop slowly over time. Many cases of CLL are detected by blood tests done in people for other reasons or who do not have any symptoms.

Causes, incidence, and risk factors

It is usually associated with a chromosome abnormality called the Philadelphia chromosome.

Radiation exposure can increase your risk of developing CML. You may be exposed to radiation from:

High-dose radiation treatments used in the past to treat thyroid cancer or Hodgkin’s lymphoma

Nuclear disaster

It takes many years to develop leukemia from this cause. However, most people treated for cancer with radiation do not go on to develop leukemia, and most patients with CML have not been exposed to radiation.

The chronic phase can last for months or years. The disease may have few or no symptoms during this time. Most people are diagnosed during this stage, when they are having blood tests done for other reasons.

The accelerated phase is a more dangerous phase, during which the leukemia cells grow more quickly. This phase may be associated with fever (without infection), bone pain, and a swollen spleen.

If untreated, CML progresses to the blast crisis phase. Bleeding and infection may occur due to bone marrow failure. Other possible symptoms include:

Bleeding and bruising

Excessive sweating (night sweats)

Fatigue

Low-grade fever

Pressure under the lower left ribs from a swollen spleen

Rash - small pinpoint red marks on the skin (petechiae)

Weakness

Hairy cell leukemia

Hairy cell leukemia (HCL) is an unusual cancer of the blood. It affects B cells, a type of white blood cell (lymphocyte).

Causes, incidence, and risk factors

HCL is caused by the abnormal growth of B cells. The cells look "hairy" under the microscope because they have fine projections coming from their surface.

HCL can lead to low numbers of normal blood cells.

The cause of this disease is unknown. It affects men more often than women. The average age of diagnosis is 55.

Symptoms

Easy bruising or bleeding

Excessive sweating (especially at night)

Fatigue

Feeling full after eating only a small amount

Recurrent infections and fevers

Swollen lymph glands

Weakness

Weight loss

Diagnosis

Acute lymphocytic leukemia (ALL)

A physical examination often reveals a swollen spleen. A complete blood count (CBC) shows an increased number of white blood cells.

Other tests include:

Bone marrow biopsy

Blood and bone marrow testing for the presence of the Philadelphia chromosome

Platelet count

Acute myelogenous leukemia (AML)

The doctor will perform a physical exam. There may be signs of a swollen spleen, liver, or lymph nodes.

A complete blood count (CBC) shows anemia and a low number of platelets. A white blood cell count (WBC) can be high, low, or normal.

Bone marrow aspiration will show if there are any leukemia cells.

If your doctor learns you do have this type of leukemia, further tests will be done to determine the specific type of AML. There are eight subtypes of AML. They range from M0 to M7, based on which blood cells are abnormal.

Chronic lymphocytic leukemia (CLL)

Patients with CLL usually have a higher-than-normal white blood cell count.

Tests to diagnose and assess CLL include:

Complete blood count (CBC) with white blood cell differential

Bone marrow biopsy

CT scan of the chest, abdomen, and pelvis

Immunoglobulin testing

Lactate dehydrogenase test

If your doctor discovers you have CLL, tests will be done to see how much the cancer has spread. This is called staging.

There are two systems used to stage CLL:

The Rai system uses numbers 0 to IV to group CLL into low-, intermediate-, and high-risk categories. Generally, the higher the stage number, the more advanced the cancer.

The Binet system uses letters A-C to stage CLL according to how many lymph node groups are involved and whether you have a drop in the number of red blood cells or platelets.

Some newer tests look at the chromosomes inside the cancer cells. The results can help your doctor better determine your treatment.

Chronic myelogenous leukemia (CML)

A physical examination often reveals a swollen spleen. A complete blood count (CBC) shows an increased number of white blood cells.

Other tests include:

Bone marrow biopsy

Blood and bone marrow testing for the presence of the Philadelphia chromosome

Platelet count

Hairy cell leukemia

During a physical exam, the doctor may be able to feel a swollen spleen or liver. An abdominal CT scan may be done to evaluate this swelling.

A complete blood count usually shows low levels of white and red blood cells as well as platelets.

Treatment

What now? It’s the most natural question to ask when you receive a cancer diagnosis. And it’s a question that’s hard to answer when dealing with the emotions and thoughts that inevitably overwhelm you after you’re given your test results. We understand this is a difficult time for you and your family. That’s why we offer the following treatment programs to all of our oncology patients in the Alegent Creighton Health system.

Acute lymphocytic leukemia (ALL)

The goal of treatment is to get the blood counts back to normal. If this occurs and the bone marrow looks healthy under the microscope, the cancer is said to be in remission.

Chemotherapy is used to treat this type of leukemia.

The first time you receive chemotherapy, you may need to stay in the hospital for several weeks.

Later you may receive chemotherapy as an outpatient, meaning you come to a clinic to receive the treatment

If you have a low white blood cell count, you may need to be placed in a hospital room by yourself so you do not catch an infection.

ALL may spread to the brain and spinal cord.

Chemotherapy drugs givent through a vein cannot reach these areas. Therefore, you may also receive:

Chemotherapy given directly into the space around your brain or in the spinal column

Radiation therapy to the brain

You may also receive chemotherapy from time to time to prevent the cancer from coming back.

If your leukemia returns or does not respond to other treatments, a bone marrow or stem cell transplant is usually recommended. A bone marrow or stem cell transplant may also be recommended if you have a brother or sister who is a complete match, or if you have a high-risk type of leukemia.

Additional treatments depend on other symptoms.

They may include:

Transfusion of blood products, such as platelets or red blood cells

Antibiotics to fight infection, especially if a fever occurs

Acute myelogenous leukemia (AML)

Treatment involves using medicines to kill the cancer cells. This is called chemotherapy. But chemotherapy kills normal cells, too. This may cause side effects such as excessive bleeding and an increased risk for infection. Your doctor may want to keep you away from other people to prevent infection.

Most types of AML are treated the same way. However, a form of AML called acute promyelocytic leukemia (APL) is treated with a medicine called all-trans retinoic acid (ATRA). This medicine helps leukemia cells grow into normal white blood cells.

The drug arsenic trioxide is for use in patients with APL who do not get better with ATRA or chemotherapy.

Chronic lymphocytic leukemia (CLL)

No treatment is usually give for early stage CLL. However, the patient must be closely monitored by their health care provider.

If chromosome testing suggests that you have a high-risk type of CLL, treatment may be started earlier.

Fludarabine, chlorambucil, cyclophosphamide (Cytoxan), and rituximab (Rituxan) may be used alone or in combination.

Alemtuzumab (Campath) is approved for treatment of patients with CLL that have not responded to fludarabine.

Bendamustine is a newer drug recently approved for use in patients with CLL that has come back after initial treatment.

Rarely, radiation may be used for painfully enlarged lymph nodes. Blood transfusions or platelet transfusions may be required if blood counts are low.

Bone marrow or stem cell transplantation may be used in younger patients with advanced or high-risk CLL. A transplant is the only therapy that offers a potential cure for CLL.

Chronic myelogenous leukemia (CML)

A medicine called Imatinib (Gleevec) is the first treatment for everyone with CML. Gleevec is a pill, taken by mouth. It is associated with very high rates of remission and survival. New medications similiar to Gleevec include dasatinib (Sprycel) and nilotinib (Tasigna).

Sometimes a chemotherapy medicine called hydroxyurea (Hydrea) is used temporarily to reduce the white blood cell count if it is very high at diagnosis.

The blast crisis phase is very difficult to treat, because it is marked by a very high count of immature white blood cells (leukemia cells). It is treated similarly to acute myeloid leukemia (AML) or acute lymphoid leukemia (ALL).

The only known cure for CML is a bone marrow transplant or stem cell transplant. You should discuss your options in detail with your oncologist.

Hairy cell leukemia

Treatment may not be needed for the early stages of this disease. Some patients may need an occasional blood transfusion.

If treatment is needed because of very low blood counts, a variety of chemotherapy drugs can be used. A drug called cladribine is used. In most cases, chemotherapy can relieve the symptoms for many years. (When the signs and symptoms go away, you are said to be in remission.) Interferon can relieve symptoms but is unlikely to lead to remission.

Removing the spleen may improve blood counts, but is unlikely to cure the disease. Antibiotics can be used to treat infections. People with low blood counts will receive growth factors and, possibly, transfusions.

Stem Cell Transplant Program

Peripheral stem cell transplant is a procedure where diseased bone marrow is destroyed and healthy new stem cells are re-infused back into the body through a vein. The healthy stem cells find their way to the destroyed bone marrow, engraft, and begin producing normal blood cells. Stem cells are found in bone marrow and peripheral blood.

Diseases Treated by Autologous Stem Cell Transplant

Leukemia

Multiple Myeloma

Lymphoma, Hodgkin Lymphoma, Diffuse Large B-Cell Lymphoma

Description/Definition of Stem Cell Transplant

Allogeneic – Removal, storage and re-infusion of donor stem cells based on tissue typing, may not be a relative

Syngeneic – Removal, storage, and re-infusion of stem cells from an identical twin

Cancer Medical Team

Your cancer medical team consists of a multi-disciplinary team of highly skilled professionals who care for every patient of the Alegent Creighton Health Cancer Center. Using state-of-the-art technology and treatment regimens, our doctors, nurses and other healthcare professionals treat more cancer patients than any other health care provider in the Nebraska.

Cancer Nurse Navigator Program

A Cancer Nurse Navigator is an oncology-certified nurse who is available to guide you and your family through the entire process of diagnosis and treatment at Alegent Creighton Health. The Cancer Nurse Navigator is a single point of contact who will be there with you every step of the way.

Support Staff

The Alegent Creighton Health Cancer Support Team is comprised of a group of healthcare professionals who work together in a variety of ways to help the patient and family cope with cancer. Individual team members include Cancer Support Services Specialists, Medical Social Workers, Cancer Rehabilitation Specialist, Pastoral Services, Dietitians, Oncology Nurse Navigators, Hospice & Home Care Services, Inpatient Nursing Services, Radiation Oncology, and Volunteer Services.

Technologies & Therapies

TomoTherapyAlegent Creighton Health is the first in the Omaha area to offer the TomoTherapy® Hi·Art® (Highly Integrated Adaptive Radiotherapy) System. This all-in-one solution allows doctors to check the location of tumors before each treatment, then deliver painless, precise radiation therapy resulting in unmatched accuracy for cancer patients, especially those with breast, lung and prostate tumors.

BrachytherapyAlthough brachytherapy is a very popular and proven treatment for cancer, using brachytherapy instead of external beam radiation for breast cancer is a recent idea. Brachytherapy has the advantages of being a shorter treatment, and irradiating less of the body. Alegent Creighton Health has strict eligibility guidelines for patients who are candidates for partial breast irradiation.

Cancer Clinical Trials

We believe our patients should have access to the most advanced medicines or treatments available. Studies are available for cancer control, cancer prevention and cancer treatment. No patient is obligated to participate in cancer clinical trials and may withdraw at any time. However, those who do participate gain access to new medicines and other benefits, such as low or no-cost drugs and treatments.

Image Recovery Center

While cancer treatment outcomes are improving, hair loss, weight changes and skin changes leave you feeling like a shadow of your former self. At Alegent Creighton Health, we won’t let you face those challenges alone. The Image Recovery Center is an appearance-enhancement program designed to help you copy with some of the physical side effects of cancer treatment.

Second Opinion Program

Alegent Creighton Health offers a Peripheral Blood Stem Cell Transplant Program for eligible patients. After you receive a cancer diagnosis, you will likely have many questions. It’s helpful to obtain as much information as possible to make informed decisions about your cancer management and treatment in order to feel confident about your care. Getting a second opinion from the Alegent Creighton Health Cancer Center can help with these concerns.

Cancer Inpatient Services

For more acute, palliative or end of life phases of cancer care, Alegent Creighton Health offers five locations throughout Omaha for inpatient cancer care services.